Monday, January 7, 2013

Evaluation & Management (E/M) "encounter form"

OK, we're all freaking out about the new psychiatry billing codes and the documentation requirements that go along with them, right? Especially the E/M codes that replace the 90862 medication follow-up.

Over the weekend I made up a form that may help. (You can skip to the end for the links to download it if you want to cut to the chase.)

The form can be printed out and filled in, either during a session, or afterwards; alternatively, it can be used for reference, to learn the coding system. It captures—I think—all of the bits of documentation mentioned in the E/M documentation standards for psychiatry. I tried to make it so that the various pieces are grouped together logically, with reasonably good design. It contains the standards and criteria for all the psychiatry E/M codes that I'm aware of: inpatient, outpatient, initial, subsequent, and all the levels. (The reference sheet that I did that is available here only does levels 2-4, and only the outpatient follow-up codes; but it does include the psychotherapy codes and add-ons, and the simpler non-E/M evaluation codes, which this one doesn't.)

The form is not

something that contains all the elements of a complete medical record note; like the E/M documentation standards, it omits a number of very basic things like, uh, a medication list, a plan, etc. I may do a second page at some point.

a guide to how you should conduct an interview

something that can be filled out on line, though it would be possible to turn it into an electronic form, and I may do that at some point

any kind of endorsement by me of this whole scheme of coding, billing, and documentation, although—even though I am someone who does not take care of the most complex medication patients—I am sympathetic with the idea that people who do should get paid more

I haven't used it yet, or piloted it in any significant way. I sent it to a few people and the feedback was positive, so I think it's worth a try. One of the complaints about the new system is that people worry that they will spend more time thinking about the documentation than about the patient. It's true that people who are very anxious about the change may do that. As I mentioned in the other post, I think that the vast majority of outpatient med visits will be 99213s, and these are not so hard to document. So I believe it's possible to get familiar with the system while we're doing pretty much what we've been doing, and we'll need to learn to adequately document what we've been doing to meet the standards. I think that for outpatient psychiatrists, if you start by using the non-E/M code for initial visits, and you try to understand the difference between 99212 and 99213, all of which is outlined on the other sheet, you will be off to a good start and in fact you may have done everything you need to do. Others will want to use 99214, and the E/M codes for initial visits. More power to them.

Some ways you might use it:

I originally thought of printing this form two-sided. It should work well for that, but when I realized that the note will need more than is on the form, I thought I might print it on two pages and use the back for additional notes. It should work fine for this as well because the name is repeated at the top of the second page.

Rather than using it in the session, you could sit down after a session and see where all the data you gathered fits on it, and then use it to see where you are in terms of coding.

It can be used as a way to understand the coding system.

As with the reference sheet, I am providing this in the spirit of "open source." There is a link to the pdf below, but you can also download the Word .doc file and change it. You can redistribute it freely as is. If you change it, you should just include attribution. Easy. Free. (As mentioned on the other page: donations welcome, via the "Support" button on the right.)

Also as mentioned on the other page: this is a good faith reflction of my understanding as of the moment of the writing. I am making no representation that it is entirely correct or problem-free, and the responsibility for your coding or documentation rests, as it always has, with you. But I hope this helps.

At the moment, the "current" version and the "original" versions are exactly the same, but if I change the form, as I expect I will from time to time, I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original. Each intermediate version should have a blog entry so that it can be found as well.

Good luck! Feedback welcome, as long as you're not blaming me for this whole imbroglio.

6 comments:

Isn't there a way to get to 99214 easily by doing 2 of 3 ({history and exam} but eliminating medical decision making)

First you would use the mental status (with at least 9 bullets)in place of history and vitals per the 1997 CMS E/M psychiatry specialists one system exam exemption.

Second you would do a detailed history with either 3 chronic conditions or 4 acute elements eg(GAD, history of EtOH abuse, MDD in remission), 1 past social or family history detail eg(family hx or depression), and a short review of systems that can have 2-9 elements (eg back pain, high blood pressure)

Voila you are done 99214Correct me if I am wrong and it is more complicated than I am making it seem. From the looks of it though, for most of our chronic complicated patients it should be pretty straight forward to get higher reimbursement since we now must use E and M codes.

Hi, sorry for the delay, I somehow managed to miss your comment! I haven't checked every detail of what you're saying but it seems accurate to me. My sense is, though, that almost all our patients will hit "moderate" complexity on the decision making. For example, if you have documented 3 problems (depression, insomnia, weight gain, anxiety...), and you are managing prescriptions (continue present medications) it seems like that should hit the criteria. Seems like this is easier than, say a 9-bullet MSE. But if you are doing that detailed an MSE anyway, it would make sense.

Glad it's helpful, thanks for the comment! It can be a lot to take in at the beginning but I don't think it needs to be chronically overwhelming. PS contributions always welcome via the "Support" button on the right-hand margin ;-)

About Me

I am a psychiatrist in private practice in Belmont, MA, USA, and a Lecturer (Part-Time) in Psychiatry at Harvard Medical School. The main focus of my practice, teaching, and writing is Intensive Short Term Dynamic Psychotherapy (ISTDP).